“Denial is not an option”
Andrew M. Cuomo, Governor of New York, June 18, 2013
1. There is much talk in the media of a heroin “epidemic”. Is the situation as bad as that?
This is a tough question to answer definitively. It is certainly clear that the number of heroin deaths in the U.S. is rising, and rising fast, and this fact has sparked a great deal of official alarm at the federal, state and local levels.
In March Attorney General Eric Holder called the 45 percent increase in the number of heroin overdose deaths between 2006 and 2010, “an urgent public health crisis”, but stopped short of calling it an epidemic. It is quite difficult to tally the precise number of heroin overdoses and deaths because of inconsistencies in the way drug-related deaths are investigated and reported across the country. Lauretta Grau, an epidemiologist at Yale University was interviewed about this problem by the New Haven Register and observed that a variety of entities, including hospitals, emergency medical services, medical examiners and police collect information and that compiling reports from all of these sources and analyzing them requires time and manpower, as well as the money to pay for these resources. The difficulty of estimating the scope of the problem is compounded by the fact that many medical examiners, coroners and doctors who fill out death certificates don’t specify the drugs that contributed to a death by overdose.
The most recent data from the Centers for Disease Control (CDC) dates back to 2010 and indicates that 3036 people died that year from heroin overdoses. However, the CDC cautions that, due to the kind of problems that plague the system for conducting investigations and documenting deaths, this estimate is probably at least 25 percent below the number of actual fatalities.
Certainly, opiod abuse overall is a terrible problem. According to the CDC, the number of people that died from drug overdoses between 2000 and 2010 more than doubled, from 17,000 to over 38,000. Sixty percent of the 38,329 drug overdose deaths in the United States that occurred in 2010 were related to pharmaceuticals. 75% of these deaths, or 16,651, involved opioid pain relievers, also called prescription painkillers.
2. Why is heroin use surging now?
Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA) says surveys indicate 80 percent of recent heroin addicts switched from opioid pain pills..
The frightening rise in the abuse of prescription painkillers, including OxyContin, Vicodin and Percocet led to efforts by law enforcement to curb easy access to these drugs. For example, there were efforts to reduce the practice of “doctor shopping”, wherein patients hop from physician to physician in order to collect prescriptions for opiates they will abuse, and to disrupt the operation of “pill mills,” a term used to describe spurious pain-management clinics that recklessly dispense prescription painkillers with the sole purpose of racking up profits. (Read more here: http://goo.gl/vXI2Vx) These efforts have met with some success, especially with regard to promoting prescription drug monitoring programs (PDMPs). These are databases that physicians and sometimes other health care providers can access to see what kinds of medications are being prescribed, and to whom. In 2006, only twenty states had PDMPs. Currently, 49 states, the District of Columbia and one U.S. territory (Guam) have legislation authorizing the creation and operation of a PDMP. Drug companies have also tried to curb abuse of opiates by making their pills harder to crush and snort.
Unfortuntely, it appears that when opiate addicts lost relatively easy access to prescription painkillers, many of them turned to heroin to feed their addictions. They found heroin not only easier to come by, but cheaper by far than prescription painkillers. Why? The Washington Post reports that drug farmers in Mexico have responded to falling prices of marijuana–that seem partly the result of decriminalization of that drug in parts of the U.S.– by planting fields of opium poppies. The Post article, published after Attorney General Holder raised the alarm about the spread of heroin use, noted that U.S. authorities seized 2,162 kilos of heroin along the border with Mexico last year, which set a record and represented an increase from 367 kilos in 2007. As a result, while prescription pain pills now cost $20 to $60 apiece, heroin costs $3 to $10 a bag. Joel Achenbach, in another article in The Washington Post, compared the problem to “pushing on a bean bag chair” and explained that in Maryland, during the first seven months of 2012, a 15 percent drop in pharmaceutical opiod overdoes was accompanied by a 41 % increase in heroin overdoses.*
3. Why is heroin so hard to give up?
Heroin addiction is a complex phenomenon, but one way to begin to understand its power is to think about how learning occurs in the brain, with a focus on the role of the neurotransmitter dopamine in activating the reward mechanisms in the brain. When we encounter a potentially rewarding situation, substance or person, the cerebral cortex signals the ventral tegmental area of the brain to release dopamine into the reward regions of the brain, which include the amygdala, the prefrontal cortex and the nucleus acumbens. My favorite explanation about the importance of dopamine is one I found by Martha Burns, Ph.D., a practicing speech language pathologist who also serves on the Faculty of Northwestern University medical staff of Evanston-Northwestern Hospital in Evanston, Illinois. Dr. Burns says:
“I like to refer to dopamine as the “save button” in the brain. When dopamine is present during an event or experience, we remember it; when it is absent, nothing seems to stick.” (Read more at: http://goo.gl/DvjnHM)
As Dr. Burns goes on to explain, the reward mechanisms of the brain help us to “stay focused and repeat activities that were reinforced through positive outcomes – whether it is finding and returning to a location where good things happened in our life or just remembering interesting information.” All drugs of abuse trigger the release of dopamine into the reward regions of the brain and they release it faster and in far greater amounts than we’re used to receiving. As I’ve explained in previous posts, if this flood of dopamine is triggered on a regular basis by ingesting drugs or engaging in other addictive behaviors such as binge-eating or gambling, the brain changes in order to protect itself against the deluge of dopamine. It begins to produce less dopamine on its own and becomes less sensitive to it as well. This is why addicts develop tolerance to their drug or activity of choice and constantly need more of it to achieve pleasure. Eventually, they must use drugs or addictive activities just to feel normal. Moreover, their diminished ability to produce dopamine means they derive far less pleasure from “ordinary” rewards of life, including activities and people that, in the past, made them happy. Over time they withdraw from these people and things. At the same time, people, places and things that are associated with the euphoric feelings achieved when using become capable of exciting the dopamine response on their own, and thus become far more interesting. 12-step programs call these entities “slippery”, because they trigger craving for the actual addictive substance or activity. Eventually addicts become almost completely preoccupied with pursuing and using their drug of choice, in order to get the dopamine flood underway.
Another aspect of heroin’s appeal may be it’s impact on the stress hormone cycle. Research indicates that drug abuse patients are more vulnerable to stress than the members of the general population. Investigators are uncertain whether this hypersensitivity to stress exists before addicts begin using drugs or is the result of chronic drug abuse on the brain or represents a combination of the two. In any case, the stress hormone cycle is controlled by stimulatory and inhibitory chemicals in the brain and the blood. Among these chemicals are neurotransmitters called opiod peptides that are chemically similar to heroin. A report from the National Institute on Drug Abuse notes that Dr. Mary Jeanne Kreek of Rockefeller University in New York City discovered evidence that opiod peptides inhibit the release of stress-related neurotransmitters in the brain and thus, curb stressful emotions. The NIDA report speculates that “when people take heroin or morphine, these drugs add to the inhibition already being provided by the opiod peptides” and it cites Dr. Kreek’s hypothesis that “some people who have difficulty coping with stressful emotions might (start taking these drugs and find that they) blunt those emotions, an effect that they might find rewarding. This could be a major factor in their continued use of these drugs.”
4. Why is heroin so dangerous?
Heroin and other opiates are central nervous system depressants . They are highly effective pain relievers because they depress nerve transmission in sensory pathways of the spinal cord and brain that signal pain. However, these drugs also inhibit activity in the parts of the brain that control breathing. A frightening problem for heroin addicts is that, while heroin changes many parts of the brain, these changes occur at different rates in different parts of the brain. Addicts develop tolerance to the euphoria that heroin produces more quickly that they develop tolerance to its ability to slow, and stop their breathing. After the death of Philip Seymour Hoffman, an article in the National Geographic Daily News explained that, as the reward regions of the brain develop tolerance to the drug, and are screaming for ever-increasing amounts of it, the “primitive centers that control breathing and heart rate are not building up tolerance at the same pace and are whispering “Enough.” With too much heroin, the brain stops sending its automatic messages for the continuation of heartbeats and breathing, and the person dies of an overdose. As the National Geographic article observed, matters are complicated by the fact that each dose of heroin an addict ingests is different, and this makes it hard for them to calculate their tolerance. Moreover, many addicts bounce back and forth between recovery and relapse, which alters their tolerance in ways that are impossible to calculate on any given occasion. Fluctuating tolerance levels create a significantly increased risk of fatality for heroin users immediately after they are released from prison and when they stop treatment.
Addicts are also at an increased risk for overdose when they use in an unfamiliar environment. Again, the brain learns to associate drug use with particular people, places and things that are present during ingestion of the drug. These entities acquire the power to activate craving, as noted above. However, they also acquire the ability to signal the brain to protect itself by secreting opiate antagonists, substances that bind to the opiate receptors in the brain without activating them and thus block the brain from receiving the full impact of the drug. Siegel et al (1982) gathered data on heroin overdose deaths in humans after noting unusual variation in experimental animals’ tolerance to opiates. They found that heroin deaths tended to occur in unfamiliar environments. As they examined this finding in relation to their animal studies, they concluded that when addicts use heroin in an unfamiliar setting or after a period of abstinence, their bodies fail to perform the anticipatory response of secreting the protective opiate antagonists.
5. What is the best treatment for heroin addiction?
The National Institute on Drug Abuse (NIDA) has published Principles of Effective Treatment and these are important for any individual or family considering treatment for addiction to review carefully. There are 13 principles, but here are three highlights.
NIDA stresses that remaining in treatment for an adequate period of time is critical. The Institute reports that research shows that addicts need at least 3 months in treatment to reduce or stop use and that “the best outcomes occur with longer durations of treatment.” The Institute emphasizes that detox is the first stage of treatment, not an intervention that is likely to bring the addict’s struggle to an end.
Why is extended treatment necessary for heroin addicts? An article by Kosten and George (2002) explained that while the brain changes that produce physical dependence on heroin appear to resolve within days or weeks after complete abstinence,
“(t)he abnormalities that produce addiction… are more wide-ranging, complex, and long-lasting. They may involve an interaction of environmental effects—for example, stress, the social context of initial opiate use, and psychological conditioning—and a genetic predisposition in the form of brain pathways that were abnormal even before the first dose of opioid was taken. Such abnormalities can produce craving that leads to relapse months or years after the individual is no longer opioid dependent.”
Studies like this lead NIDA to urge consumers and patients to view addiction as similar to other chronic illnesses. Relapse is common and doesn’t mean treatment has failed. What it does mean is that “treatment should be reinstated or readjusted”. One of my recent posts noted that practicing physicians who enter treatment for opiate addiction achieve astounding rates of abstinence as compared to the general of people in recovery– between 74% and 90% . The difference between physicians and the general population is that the former usually receive 90 days of residential treatment and five years of monitoring with random drug tests. As a result, rates of recovery exceed 80 percent, even five years after treatment.
Another idea that NIDA advances is that behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. Family involvement is essential for many reasons. It is instinctive for family members to want to protect a loved one from frightening legal, vocational and personal consequences of drug abuse, but shielding addicts from consequences typically interferes with recovery by clearing the way for the addict to continue to use. It can be hard for family members to distinguish needed support from “enabling” behaviors, and family treatment can be very helpful to them (and by extension, to the recovering person) by clarifying the difference. And, once again, family education is crucial because it helps everyone to understand and accept the nature of this chronic medical disorder, hold realistic expectations about the time it will take for their loved one to stabilize in recovery and respond constructively in the likely event of relapse.
Recovering people and their families often have questions about the place of medications in addiction treatment. NIDA stresses that medications are frequently an important element of treatment, especially when used in conjunction with counseling and other behavioral therapies. It calls medications a “critical component of opiod addiction treatment”. There are a number of medications that appear to assist in recovery from heroin addiction. These medications act on the same brain receptors as the opiates do, but they are safer and less likely to lead addicts to engage in destructive behaviors. Methadone is an opiod agonist. It acts like an opiate when it reaches the receptor, but is taken orally, so it takes longer to reach the brain. Methadone reduces the intensity of an addict’s high, and it prevents withdrawal. Buprenorphine (Subutex) is a partial opioid agonist. It relieves the addict’s cravings, but does not produce a “high” and does not carry the dangerous side effects of other opiates. Suboxone is taken orally and is a combination of of buprenorphine and naloxone (which is an opioid antagonist). It is used to discourage addicts from getting high by injecting a medication. If an addict injects Suboxone, the naloxone in the medication induces withdrawal symptoms. This does not happen when the drug is taken orally, as prescribed. It is typical for Subutex to be given during the first few days of treatment and for Suboxone to be used during the maintenance phase of treatment. At this time, methadone can only be dispensed by clinics that specialize in addiction treatment. Subutex and Suboxone can be prescribed in a doctor’s office. You can read more about these drugs on the FDA’s Subutex and Suboxone website.
NIDA emphasizes that:
Scientific research has established that medication-assisted treatment of opioid addiction increases patient retention and decreases drug use, infectious disease transmission, and criminal activity.
Certainly, there is much more that can be said about the heroin crisis and effective responses. Please let me know if there are other questions you would like me to address and I will provide whatever information I can.
Addendum: A few hours after I posted this article, the CDC published information pertaining to opiod deaths during 2011. Their statistics indicate that deaths due to prescription painkillers followed a more than decade-long trend and increased about 2% to 16,917. Heroin deaths, however, rose by 44% — from 3,036 in 2010 to 4,397. Medpage Today reported that the CDC continues to believe that the rise in heroin deaths is partly due to the decreased availability of prescription opiods and quoted remarks made by Dr. Andrew Kolodny, chief medical officer of Phoenix House, a national addiction treatment organization, after he reviewed the CDC’s figures for 2011. Dr. Kolodny said:
I see this as all the same problem, an epidemic of people addicted to opioids. Treatment has to be easier to access than pills or heroin.”
Read more about addiction and the family in Dr. Wood’s books: Children of Alcoholism: The Struggle for Self and Intimacy in Adult Life and Raising Healthy Children in an Alcoholic Home
Categories: addiction, addiction and recovery, Addiction as a Brain Disease, Anti-craving medications, heroin addiction, heroin crisis, heroin epidemic, heroin overdose deaths, Naltrexone, Naltrexone treatment for opiate addiction, prescription painkillers, Suboxone treatment for heroin addiction, substance abuse, substance abuse and recovery, treatment for heroin addiction